Malignant hemispheric infarction following surgical evacuation of spontaneous intracerebral haemorrhage. a case report and narrative review

Malignant cerebral hemispheric infarction following evacuation of spontaneous intracerebral haemorrhage is an exceedingly rare, life-threatening complication with poorly understood pathophysiology and no established management guidelines. We present a case, review the published literature, analyse the proposed aetiological and pathophysiological mechanisms, and discuss future directions for management. We report a 44-year-old known hypertensive female with a right temporoparietal spontaneous intracerebral haemorrhage who had a craniotomy with clot evacuation. Despite initial postoperative improvement, she developed sudden neurological deterioration 8 hours after surgery. Postoperative cranial CT scan revealed an extensive ipsilateral hemispheric infarction with mass effect. She received aggressive neurocritical care; however, she died 24 hours after surgery. Malignant cerebral hemispheric infarction following surgical evacuation of spontaneous intracerebral haemorrhage is an uncommon but potentially fatal complication. Available evidence suggests a multifactorial process involving the neurotoxic effects of blood and its degradation products, direct vascular compression, iatrogenic neurovascular manipulation, vasospasm, haemodynamic alterations, abrupt blood pressure lowering in the setting of disrupted autoregulation, and coexisting vasculopathy, amongst others. Prospective multicentre studies incorporating serial vascular, perfusion, and haemodynamic assessment are needed to clarify the underlying mechanisms and inform preventive and management strategies.